Cerebral Palsy (cont.)

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

What are specific treatment plans for cerebral palsy?

After the initial evaluation, specific treatment plans are outlined for each child:

Seizure medication

If the child has seizures, the treatment is based on the type and frequency of the seizures. Complete seizure control can often be achieved using a single medication, but some children with cerebral palsy have particularly difficult-to-control seizures. Medication can have side effects affecting the brain, ranging from sedation to hyperactivity. They can also affect liver function, white and red blood cells, and bone metabolism. Side effects are usually not harmful and resolve when the offending medication is discontinued. The goal of the treating physician should be for the child to become seizure free with few or no side effects. It must be noted that it is of no benefit to the child to be seizure-free but significantly impaired by medication side effects.

Medications for spasticity: The treatment of spasticity can involve multiple health professionals. Treatments involve the use of medications and surgical procedures to decrease the spasticity, facilitate movement, and prevent contractions. Among the most common medications are dantrolene sodium (Dantrium) and diazepam (Valium). Diazepam is both a muscle relaxant and a sedative. Baclofen (Lioresal) can be taken by mouth or infused continuously with an implanted pump (intrathecal infusion) directly in the cerebrospinal fluid (the liquid that bathe the spinal cord and the brain). This treatment might be specifically useful for patients with spasticity in the lower legs. The most common complications with these medications are drowsiness, sleepiness, and some degree of weakness. The sedative side effects of such medications often limit their usefulness. In the case of the baclofen pump the most common complication seen in a small number of patients is the infection of the catheter. Additionally, a muscle relaxing agent called botulinum toxin can be injected into tight muscles to relax them. When used prudently, this procedure may prevent surgical intervention.

Surgery

Surgery for spasticity: In the case of severe muscle spasticity, surgery may be a valuable option. Tendon release procedures, usually performed by an orthopedic surgeon, allow improved range of motion in some cases. Such procedures are usually performed on the muscles of the calf or inner thigh. A less commonly used procedure, is the dorsal rhizotomy. During this operation, the surgeon cuts some of the nerve roots that send sensory information from the muscles to the spinal cord and brain. This procedure relieves some of the spasticity and thereby helps the child walk with a more normal gait. Most neurosurgeons performing dorsal rhizotomies very carefully select only those patients whom they feel may be helped by the surgery. From time to time, other surgical interventions are required in children with cerebral palsy. In very rare cases of choreoathetoid cerebral palsy, in which the writhing movements severely limit the ability of the child to function, highly selective neurosurgical techniques can curtail these movements without significantly harming other functions.

Other surgical procedures

Ophthalmologists (eye specialists) can help strabismus by operating on the muscles that control the movement of the eye or to correct some other complications such as cataracts.

Neurosurgeons can treat intractable seizure control. Operations such as callosotomy, hemispherectomy, and focal resections of areas of abnormal brain tissue responsible for the seizures, might be indicated in some cases. An alternative procedure for the treatment of epilepsy is the vagal nerve stimulation, an implantable device, that can be useful in selected patients with difficult to control seizures.

Scoliosis, or curvature of the spine, is often the result of severe hypotonia. This condition can create discomfort for the patient and difficulty for caregivers in performing the activities of daily living. Furthermore, severe scoliosis may actually restrict a patient's ability to breathe. Several surgical procedures are available in specialized centers for the correction of scoliosis.

Children who are unable to take adequate calories by mouth may require the placement of a feeding gastrostomy tube (PEG tubes) directly into the stomach.

Therapy

The treatment of spasticity can involve multiple allied health care professionals. Physical and occupational therapists play an important role.

Physical therapy: The extent of physical therapy depends on the degree of spasticity, hypotonia, and motor impairment. The main therapeutic effect of physical therapy is maintaining range of motion at the joints, thereby preventing contractures. Some scientists and therapists feel that physical therapy actually helps maintain the connections in the brain, although this is controversial. Other skills, such as improved gait, stance, and balance can be helped by physical therapy. A strong, proactive physical therapy program greatly aids in the life of a child with cerebral palsy.

Occupational therapy: Occupational therapy assists children with the skills needed for day-to-day life in school and at home, including eating, writing, and work skills. In early infancy, occupational therapists can provide assistance in feeding a child with a poor or uncoordinated sucking response.

Speech therapy: Speech and language pathologists are involved with the development and improvement of speech production. Using different techniques the speech pathologist helps to improve the quality and the quantity of the speech production. The role of these specialists is not limited to speech production alone, but they also teach the patients other communication techniques (sign language, use of communication boards) to facilitate the communication abilities.

Medical care

Medical care of children with cerebral palsy is often seriously hampered by the inability of the child to communicate his or her needs and sensations. Relatively common childhood illnesses in children with cerebral palsy, such as ear infections, urinary tract infections, and appendicitis, which are easily treatable in most children, may prove to be life-threatening due to delayed recognition on the part of caregivers and physicians. Each child with cerebral palsy should have a primary care professional that is experienced with the special medical needs of affected children.

Because physicians have offered limited hope in curing cerebral palsy, many families have turned to alternative methods in the treatment of their children. Such therapies may include diets, herbal remedies, aromas, play with animals, and hyperbaric oxygen. The scientific evidence supporting the use of diets is inadequate. Some of them such as hyperbaric oxygen therapy, which is delivered in specialized centers, can be quite expensive and has not been scientifically proven to help children with cerebral palsy. Other remedies must be investigated on a case-by-case basis. Hopefully, the family of the affected child will be able to approach their physician regarding these alternative treatments.